NHIS Operational Guidelines Explained: Know Your Rights

NHIS Operational Guidelines: The Children Under Five Social Health Insurance Programme (CUFSHIP)

According to CUFSHIP, all Nigerian children under five years of age can receive free medical care to cover the major causes of death. If your child is suffering from malaria, diarrhoea, respiratory tract infection, pneumonia, measles, skin infections, domestic accidents or typhoid you are entitled to get medical help for free. Immunization and hospital care expenses are also included under CUFSHIP.

NHIS Operational Guidelines: HMO Responsibilities

HMO stands for Health Maintenance Organization. In an HMO health insurance plan, policyholders consult their Primary Care Physican (PCP) first in the event of a medical problem. If the PCP determines that the help of a specialist is needed, he schedules an appointment for the patient. Under NHIS, HMOs must ensure that policyholders understand their benefits. They must also recommend specialist advice when necessary and fully disclose all exclusions or restrictions on coverage that may exist in the contract. HMOs are prohibited from imposing hidden charges. Additionally, HMOs may not prevent PCPs from helping their patients get the coverage that they are entitled to under the plan.

NHIS Operational Guidelines: Private sector healthcare obligations

In Nigeria, all business that have 10 employees or more must offer healthcare. The employer must pay for at least 10% of the coverage cost. The employee is only responsible for contributing no more than 5% of the cost. The rest of the cost of healthcare is paid for by the government. If you are paying for more than 5% of your healthcare cost, contact the NHIS and report your employer.

NHIS Operational Guidelines: NHIS member rights

Once you enroll in the NHIS, you can choose to change your primary healthcare facility after six months if you are unsatisfied with the service. Once you are fully enrolled and registered, you have a right to receive medical care. You can also add up to 4 dependents to your plan. If you have more than 4 dependents, you can add more if you agree to pay a fee.

All NHIS healthcare facilities must secure a NHIS accreditation and provide services in accordance with HMO benefit packages. Also, all NHIS facilities must provide data to the NHIS and ensure patient satisfaction. Any complaints from NHIS enrolled patients must be forwarded to the NHIS for review.

NHIS Operational Guidelines: Penalties

If a NHIS accredited hospital refuses to treat a NHIS enrolled patient, the facility will be issued a fine of no less than N100,000 along with a warning and a suspension of no less than 3 months. Similarly, if an employee of a NHIS accredited hospital charges any extra fees for health services, all money must be refunded to the enrollee and the hospital will be fined no less than N100,000.

34 Comments

I added my child after the three months waiting period still I am denied medical care for the child under the scheme that the name has not been added which is not my faults, so what will I do to get refund of my my money pls.

Hello Paschal, there are no age restrictions on the NHIS platform, however children are often covered under relevant family health insurance policies which normally extends coverage to both spouses and up to 4 biological children under 18 years of age.
According to NHIS, any other member of the family outside the allowable six can always be registered as-extra dependants.

Thanks for your immediate response to my plight. The Primary health provider where I got the referral to OOUTH,Sagamu is AMESO Specialist Hospital Ojota,Lagos,Dr.Okunowo,0805567**** is in charge.
When I put a call through to my HMO,Premier Medicaid,Dr.IDOWU he said am not the one to call him ,that it is duty of the NHIS office at the hospital. OOUTH,Sagamu(0803859****)
The NHIS office says if I have to be treated for even malaria I have to get a referral ,but Dr.Okunowo declined this statement.
Is Dr.Okunowo suppose to refer me for this treatment ?
Am being driven from pillar to pole ,since I enrolled in the scheme, I never for once attend clinic until I had a fracture in my femur.
While on admission in the hospital, I bought all the essential drugs with my money.

Hi Olusegun, apologies again for all you are currently passing through. It is quite strange that your HMO faulted you for calling them. The least they could have done was listen to you and ensure to sort out any differences with your primary health provider.
Your primary health provider ought to formally ‘refer’ you for treatments they can not provide. I think the issue here now is that Malaria may not have been included in their initial referral letter. However, it is common knowledge that cases like this can be handled by your HMO. For treatments that cannot be provided by your PHP or in cases where you fall ill outside your primary domain, your HMO has the responsibility to refer you accordingly (temporarily) to another health provider so long as this provider is in their network. This is the way it works for the renowned HMOs. Again, please reach out to your HMO again to sort out these issues, they should at the very least agree to refund certain medical expenses incurred for treatments that are within your plan coverage scope.
Feel free to switch HMOs after your present ordeal is over if you are unhappy with the current one. It is not a monopoly and you should get value for your money always. Do let me know if you need further assistance.

In my opinion, I provided all the contact information hopping that you will verify my claims and prevail on them to meet my desired aspirations. Even my Primary health provider have refused to pick my call.Am currently immobilized to visit the clinic.
At this point I have to speak to a lager press,.

Hi Olusegun, you should speak to a larger press if you can. Kindly send the contact information of your PHP to support@einsurance.com.ng and we’ll help you reach out to them as well. We do not allow the phone numbers of third parties to be published on our sites as it could breach their privacy undeservedly. Only that of our company (Key Verticals Ltd) is allowed. By default the phone numbers are often broken before they can be published.

I am currently at a Teaching hospital on post surgery medical checkup .I developed high blood pressure.The consultant at the orthopedic clinic referred me to the cardiologist. I was not attended to at that clinic within the same institution.They asked i should go back to my HMO and the primary health provider .What is the right procedure?

Hello Olusegun, sorry to read about your present health condition. First you should reach out to your HMO ASAP (have their contact number stored on your phone if you haven’t done this before), then find out if your current health plan covers the required cardio related checkup/treatment. Some HMOs may have special providers they use for these kinds of treatment. There’s a lot more we need to know in order to answer appropriately, however you should reach out to your HMO and review your coverage options against the future if the current one is limited.

Hello admin…I walked to my HMO and demanded that some investigations be carried out on them, surprisingly I was billed in full with the explanation that I demanded for the investigation. That NHIS rule says that ones an individual walks into d facility to demand for an investigation you pay in full. That’s at Horeb hospital Kaduna

Mathias Iyaji… I am a soldier and I registered while i was serving at Ogun State, now am posted to Calabar though my family and I receive treatment at the Military medical facility but i prefer to register in a civil medical facility outside the Barracks. What is the way out?

Hi Mathias, you can always opt for a separate private/family health insurance cover. Although it’s a surprise to me that the Military do not have a robust HMO plan for soldiers.. I hope this is not the case. Feel free to use the “Get Quotes” form on this page to compare multiple quotes from at least 5-6 providers, then choose one that’s most suitable. The HMOs have got good nationwide coverage and even beyond.

I am self employed. I want to register as a member. Where should l go to enroll in Surulere lagos. Or can l enroll on line.
How do l pay registration fee and how much does it cost.
Thanks in anticipation

Hi Sam, normally a family health insurance plan should cover you, your wife and up to 4 of your kids. Did they tell you why your kids names were removed?
Also, you can always use the free quotes form on this site to compare free health care insurance quotes from multiple providers.

Am a member of NHIS at some time last year was told by the hospital i go for medication daughters of charity in kubwa Abuja, that they were not paid therefore, i have to pay for all the bill for some time, before i was told that they have been paid. With out paying me back what was taken from me.
It this case who is responsible to reembose me back.
Regards
Hembadoon Dorcas AJikwa

Before you use your personal funds to offset your health care bills you should inform and agree with your HMO beforehand. Thereafter you should forward all receipts and proof of payment to them by the time they commence payment. This would ensure that your HMO does not make double payment to your hospital and also ensure that you are reimbursed adequately.
Hope this helps..